JASE Foundation Comfort Cards Request
Share your contact details and how a Comfort Card would help your family—submission does not guarantee assistance.
Contact Information
Parent/Caregiver Name
*
First Name
Last Name
Email
*
example@example.com
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
Email
Text
Phone
About Your Family
City
*
State
*
ZIP Code
*
Number of Children
*
Child's Age
*
Diagnosis
*
Autism
ADHD
AuDHD
Intellectual Disability
Developmental Disability
Other
Financial Need
Are you currently experiencing financial hardship?
*
Yes
No
What are the main reasons for your financial hardship?
*
Unexpected medical expenses
Therapy costs
Reduced work hours
Lost income
Single-income household
Food insecurity
Waiting for benefits/services
Emergency expense
Increased caregiving responsibilities
Other
How urgent is your need?
*
Please Select
Within 24 hours
Within 2–3 days
Within one week
Not time-sensitive
Household income
Please Select
Under $25k
$25k–49,999
$50k–74,999
$75k–99,999
$100k+
Prefer not to answer
Additional financial information
Previous Assistance
Have you received a Comfort Card before?
*
Yes
No
If yes, approximately when did you receive it?
Optional Testimonial
Would you be willing to share a testimonial if you receive assistance?
Yes
No
Maybe
May JASE Foundation share your story anonymously?
Yes
No
Agreement
Agreement
*
I confirm that the information provided is true and complete.
I understand that assistance is not guaranteed.
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